The 30-Day Challenge: Oral Meds During the Day, Lantus at Night

Mary is a 64-year-old woman who has been diagnosed withtype 2 diabetes for 14 years. She is obese at 220 pounds.Mary has been treated with a sulfonylurea (a medication thatstimulates the pancreas to secrete insulin, such as glypizideand glyburide) for the past 10 years. Her glucose control for thepast three or four years has not been good. A recent A1C was9.5% (normal range is 4% to 6%, with a goal of 7%). Metformin(Glucophage) and rosiglitazone (Avandia) were added to hersulfonylurea. Both her pre-meal and post-meal glucose valuesimproved and her A1C came down to 7.8%. However, herfasting blood glucose levels were in the upper 100 mg/dl tolow 200 mg/dl range. She was afraid of “the needle” and didnot want to start on insulin. In addition, Mary was recentlydiagnosed with early diabetic eye disease (retinopathy) andnerve disease (neuropathy).

Unfortunately, Mary’s story is a common one. The sulfonylureahas lost its effectiveness over time, and her blood glucosevalues have been excessively high for years. As a result, she isdeveloping the classic complications of diabetes. The additionof Glucophage and Avandia helped, but she was still not atgoal.

Mary does not have many other options in terms of oralmedications. One very effective regimen is to add one injectionof an intermediate (NPH) or long-acting (Lantus) insulin atnight, in addition to taking her usual medications during theday. Mary was started on 10 units of Lantus at night, and shewas taught to self-titrate her own dose upward depending onher blood glucose levels first thing in the morning. She wasinstructed to go up one unit every night until the morninglevels were below 120 mg/dl. Her ultimate dose was 45 unitsof Lantus at bedtime; her A1C came down to 6.6%. She had noproblems with hypoglycemia and only a 3-pound weight gain.

Mary did not want to start with injections, but I told her aboutmy 30-day challenge: After one month she could stop theinsulin if the injections hurt too much (this is usually not aproblem with the very short ultra-fine needles), if the insulindid not bring down her numbers or if she felt it was nothelping her. Later Mary thanked me, gave me a big hug andapologized, saying what a sissy she had been and how happyshe is to now be in control.

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